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CDC India Malaria Risk: For Military and not average travelers?

I am starting a new post to clarify the CDC malaria guidelines for India. Footnote 3 on the CDC page states: "This risk estimate is based largely on cases occurring in US military personnel who travel for extended periods of time with unique itineraries that likely do not reflect the risk for the average US traveler." If I am interpreting this correctly, prophlylaxis may not be necessary for the average traveler.

In 2010, 931,000 Americans visited India. There were 261 reported cases of malaria with 9 fatalities. Only 4% (11 cases) were in tourists. The majority (54%) of cases were in individuals visiting friends and relatives, possibly in more remote areas. Most infections occurred in August with a second, much smaller peak in November.

Obviously if you become infected, malaria is a real problem but the data suggests the risk is quite low.

Roosevelt, go back to the cdc page where you found the footnote. That footnote is NOT attached to any portion of the text on India. The footnote is attached to the malaria risk of "high" in Afghanistan.

I know you are concerned about your upcoming trip to India. I believe you decided to use bite prevention, which for your circumstances and itinerary seems to be a reasonable plan.

It is true that people visiting friends or relatives are at greater risk for malaria, in part because they often underestimate the chances of contracting malaria and do not take precautions. Family members in India often tell them there is no problem, or they may remember never taking precautions when they were living there and not getting sick. This is complicated by the possibility of "partial immunity" (a now-disputed idea about exposure to malaria).

Still, the number of US travelers who have contracted malaria in India provides no insurance for you. The stats may be falsely reassuring, as you have no idea what those travelers were doing - docking on a cruise ship is different from visiting a tiger park, for instance. You can only make decisions based on your unique situation and all of the available information.

PS There are some areas of India with distinct seasonality for malaria and other areas that have no seasonal surge/decline pattern. This might make a difference for you if you were going somewhere in India for an extended time (6 mos or a year) but has little relevance for someone traveling in India.

As a physician, I contacted the CDC and they confirmed that the footnote does not apply to India. When you search for India alone on the CDC Travelers page, ALL footnotes for all countries are listed and it is misleading. They are going to correct that.

Interestingly, they lack epidemiological data that is relevant deciding on prophylaxis. If 11 US tourists contracted malaria in 2010, the risk must be low.

Roosevelt, glad to help. If you want to look at numbers of people who contract malaria, I think the better data to look at is the WHO data on incidence of malaria. The mosquitos don't check passports before biting. The cdc considers not only data from US visitors, but they consider the WHO data in making recommendations for prophylaxis. They also share information with other countries. The British have a goodly amount of data as well. You can check their NHS Fit For Travel website for their recommendations and their excellent malarial risk maps.

That explains the difference between the CDC and U.K. recommendations. The U.K. designates northern India as low to no risk and recommends bite prevention only. If I lived in the U.K. I would not be prophylaxing.

The epidemiology is important. Risks that have very low probability are often worth taking.

This is the verbatim response I received from the MD at the CDC regarding the apparent low epidemiological risk:

"That is not the right way to determine risk. Keep in mind that most people who travel to India take chemoprophylaxis. Thus, there would have been much greater numbers of cases of malaria if no one had used any preventive measures. Yes, malaria chemoprophylaxis is recommended for travel to India as you describe."

Hi Roosevelt, thanks for posting the CDC response. I agree with them that the number of travelers who contract malaria does not represent the epidemiological risk, which is why I find the numbers from WHO so useful. They reflect the number of reported cases in an area - local or traveler. But even the WHO numbers are an underestimate, as they rely on reporting. In some places the reporting is very poor. India, despite its advances in many areas, still vastly underreports the incidence of malaria. The last figures I read indicated that they estimated that India underreports by a factor some somewhere between 2 and 10.

The additional information you provided has been very helpful. It appears that the real malarial risk is much higher than one would extrapolate from epidemiological data. It changes my risk equation and I will most likely opt for prophylaxis.

The travel doctor I am going to see next week appears to also prescribe Lariam as well as Malarone.
I have read that Malarone has side affects (vomiting, diarrhea and in extreme cases renal failure) so clearly this is not without it's disadvantages.
As Roosevelt states he had an adverse reaction to Malarone in the past.

Larry is there a specific reason why you choose Lariam over Malarone of Doxycycline?

It seems choosing the "right" drug is a conundrum because I either way you choose to go there are risks involved.

I took one dose of Lariam and had very bad nightmares and the begining of paranoia. I have taken Malarone for weeks at a time with no side effects whatsoever. Everyone's system is different, but I think the risks with Lariam are too high. Roosevelt - did you take the Malarone with food?

It was recommended by an infectious disease specialist. At the univ. medical center I work at. This was probably at least 15 yrs. ago. My wife, son and me have taken it every time we've gone to India, about 3-4 times and have had no issues or side effects. My current PCP, also and id specialist has prescribed it for me since and we've been fine. I have head about the neurological some have experienced. What can I say except that it works for us.

Thanks for you reply Larry. If I had taken Lariam in the past without any adverse affects I would probably continue to take it. As Thursdaysd points out, everyone's body is different but never having taken either of the drugs, so far it seems that Malarone's possible side affects are more benign.

While Malarone has the fewest side effects (and those you've read about as being dire are almost always at treatment doses, not prevention doses), there are people who can't tolerate Malarone. Roosevelt is one of those people, Craig, another regular poster is another.

Larium is the ant-malarial with the most side effects and the greatest proportion of people who have side effects can be used without problems by many, like jacketwatch. If you choose Larium, you will be advised to take a test dose a few weeks before you travel. IF you are going to have serious side effects from Larium, it is usually evident within the first two doses. Also, there is Larium resistance in SE Asia - Cambodia, border areas of Thailand and Burma.

Doxycycline tends to have rather minor side effects for most people - increased sun sensitivity, vaginal yeast infections or women - but since it has to be taken at about the same time every day and must be continued for 4 weeks after leaving the malarial risk area, there are more opportunities to miss doses which impacts effectiveness dramatically.

Dehydration is another factor to consider. I worry about not finding bathrooms on these types of trips and consume less fluid, which may alter the toxicity of some medications. I need to focus on doing a better job of hydrating when taking these medications.